LIC 9165 — Board of Director Statement
LIC 9165 is the California CDSS form titled "Board of Director Statement". Identifies the governing board for corporate license applicants.
Official PDF
The current LIC 9165 is published by the California Department of Social Services. We link to the live source rather than hosting a copy, so you always get the latest revision.
Open LIC 9165 on cdss.ca.govWho completes it and when
The facility prepares this form and files the completed original in the appropriate record.
Filed by corporate licensees and updated when the board changes.
How to complete LIC 9165
- 1Download the current revision of the form directly from CDSS so you are not working from an outdated copy.
- 2Fill in facility and resident identifying information exactly as it appears in your licensing and resident records.
- 3Complete every section — evaluators read blanks as missing documentation.
- 4Obtain the required signatures and dates before filing.
- 5File the completed form in the resident or facility record. Filed by corporate licensees and updated when the board changes.
Mistakes evaluators flag
- Using an old revision of the form after CDSS published an update.
- Sections left blank with no explanation.
- Signature or date lines missed on the final page.
Questions about LIC 9165
When is LIC 9165 used?
Filed by corporate licensees and updated when the board changes.
Is LIC 9165 required for an RCFE?
LIC 9165 is not required for every RCFE resident or facility. It applies in the situations described in the form instructions.
Fill this form from data you already have
- Resident, staff, and facility details populate the form fields automatically.
- Track which forms are on file, which are missing, and which are about to expire.
- Incident reports draft the LIC 624 narrative and finalize an immutable PDF.
Related licensing & administration forms
RCFE OS is not affiliated with the California Department of Social Services. This guide is operational information for licensees, not legal advice. Always follow the current form instructions and guidance from your licensing analyst.